Our next chapter to address in the I-10 Corner is the Digestive System. Please review the table below so that you can see what areas of the chapter have either been expanded or restructured.

EXAMPLE

 

UPDATE

For updated information on this topic, please click here for the more recent article: Coding Guidelines for Respiratory Failure

Whether it’s ICD-9-CM or ICD-10-CM, the coding guidelines are actually the same for Respiratory Failure. The only difference is the code itself. It’s not only important for a coder to be familiar with these guidelines but also some of the basic clinical indicators as well.

DEFINITION

from Section II of the Official ICD-9-CM Guidelines for Coding and Reporting

“Principal Diagnosis”A condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care - defined by the Uniform Hospital Discharge Data Set (UHDDS).

 

NOTE FROM AUTHOR
Each admission is different. The Principal Diagnosis will not be the same in every situation. Selection of the Principal Diagnosis is dependent on the circumstances of the admission. Coders should ensure that the record contains documentation that indicates clinical credibility to support the presence of that condition. It is also important for coders to understand the clinical indicators of Acute and/or Chronic Respiratory Failure in order to establish a query when necessary.

 

Respiratory Failure

1. Life-threatening condition that may be caused by a respiratory condition as well as a non-respiratory condition.
2. Look for documented signs / symptoms of:
3. SOB (shortness of breath)
4. Delirium and/or anxiety
5. Syncope
6. Use of accessory muscles
7. Tachycardia
8. Tachypnea
9. Confusion
10. Sleepiness
11. Depressed consciousness
12. Cyanosis (bluish color to skin, lip and/or fingernails)
13. Acute Respiratory Failure is supported as principal diagnosis when at least 2 of the following critical values (ABG’s) are met.
14. pH < 7.35
15. PO2 < 55
16. PCO2 > 50
17. Keep in mind, this is a guideline and not solely to be the determining factor for   diagnosing Acute Respiratory Failure. A patient with a chronic lung disease such as COPD may have an abnormal ABG level that could actually be considered that particular patient’s baseline. What is normal for one patient could be abnormal for another. In a patient with a chronic lung condition, the physician would consider the degree of change from a patient’s baseline before diagnosing Acute Respiratory Failure.
18. Acute Respiratory Failure
19. Develops quickly
20. Usually admitted to ICU
21. Requires aggressive and/or emergency treatment via oxygen through nasal cannula, face mask, ventilation and/or tracheostomy
22. Absence of vent does not preclude diagnosis
23. Requires close monitoring and evaluation
24. Chronic Respiratory Failure
25. Develops slowly
26. Last longer
27. Home O2 is one indication of CRF

Four classifications types for ARF

• Hypoxic – most common
• Hypercapnia – often accompanied by hypoxemia
• Post-operative
• Shock – Septic, Cardiogenic or Hypovolemic

Acute Respiratory Failure as Principal Diagnosis

OFFICIAL CODING GUIDELINE

ICD-10-CM – Section I.C.10.b.1

(ICD-9-CM – Section I.C.8.c.1)

Acute or Acute on Chronic Respiratory Failure may be assigned as a principal diagnosis when it is the condition established after study to be chiefly responsible for occasioning the admission to the hospital, and the selectionis supported by the Alphabetic Index and Tabular List. However, chapter-specific coding guidelines (such as obstetrics, poisoning, HIV, newborn) that provide sequencing direction take precedence.

 

OFFICIAL CODING GUIDELINE

ICD-10-CM – Section I.C.10.b.3

(ICD-9-CM – Section I.C.8.b.3)

When a patient is admitted with Respiratory Failure and another acute condition (e.g., Myocardial Infarction, Cerebrovascular Accident, Aspiration Pneumonia), the principal diagnosis will not be the same in every situation. This applies whether the other acute condition is a respiratory or non-respiratory condition. Selection of the principal diagnosis will be dependent on the circumstances of admission.   If both the Respiratory Failure and the other acute condition are equally responsible for occasioning the admission to the hospital, and there are no chapter-specific sequencing rules, the guideline regarding two or more diagnoses that equally meet the definition for principal diagnosis (Section II.C) may be applied in these situations.

If the documentation is not clear as to whether Acute Respiratory Failure and another condition are equally responsible for occasioning the admission, query the provider for clarification.

 

When coding Respiratory Failure (or any condition) and trying to determine whether it should be assigned as principal diagnosis or not, look for:

1. All signs and symptoms at the time of admission
2. Clinical indicators
3. Supporting physician documentation
4. Treatment plans

With any record, keep in mind that because a condition may be present on admission does not necessarily mean if qualifies for principal diagnosis. You have to ask yourself these questions:

• After study, is this the condition that was chiefly responsible for admission?
• How aggressive was the work-up and treatment?
• Is there another condition that equally meets the criteria for principal diagnosis?
• Are there any chapter specific guidelines to consider?
• Could this condition have been treated as an outpatient?

I wish I could say that assigning the appropriate principal diagnosis and coding in general was as easy as ABC, but it’s not. Some are a little easier than others but there seems to always be a little gray area to muddle through. Clear and precise documentation goes a long way in helping to determine the principal diagnosis.

As you take on a record to code, forget about the one you just finished. Each record and the circumstances surrounding the admission will be different.   Always be aware of the coding guidelines and follow through the steps listed above. You’ll find that assigning the principal diagnosis will be a little easier.

This week the focus is on Chapter 12 – Diseases of Skin and Subcutaneous Tissue.   Like many chapters in ICD-10-CM, Chapter 12 has also been restructured.   Diseases that are related in one way or another have been grouped together. In ICD-10-CM, Chapter 12 has 9 subchapters:

• L00 – L08  Infections of the skin and subcutaneous tissue
• L10 – L14  Bullous disorders
• L20 – L30  Dermatitis and eczema
• L40 – L45  Papulosquamous disorders
• L49 – L54  Urticaria and erythema
• L55 – L59  Radiation-related disorders of the skin and subcutaneous tissue
• L60 – L75  Disorders of skin appendages
• L76  Intraoperative and post-procedural complications of skin and subcutaneous tissue
• L80 – L99  Other disorders of the skin and subcutaneous tissue

There is greater specificity for many of the codes at the fourth, fifth and sixth character. Examples for Decubitus (Pressure) Ulcers would be:

• Specified site (elbow, hip, sacral, ankle, back, buttock, heel, other site, unspecified site and contiguous site of back, buttock and hip)
• Laterality (right, left)
• Severity (stage)
• Classified Stage 1 through Stage 4
• Unspecified Stage
• Unstageable

Under ICD-9-CM 2 codes were required for Decubitus (Pressure) Ulcers. One code in ICD-10-CM provides:

• Ulcer site
• Laterality
• Stage
• Additional code should be assigned and sequenced first for any associated Gangrene.

CODING GUIDELINE

I.C.12.1

Pressure Ulcer Stages: Codes from category L89, Pressure Ulcer, are combination codes that identify the site of the Pressure Ulcer as well as the stage of the Ulcer. ICD-10-CM classifies Pressure Ulcer Stages based on severity, which is designated by Stages 1-4, Unspecified Stage, and Unstageable. Assign as many codes from category L89 as needed to identify all the Pressure Ulcers the patient has, if applicable.

Different stages for Pressure Ulcers:

• Stage 1 – Wounds that only involve the upper epidermis. Pre-ulcer skin changes limited to persistent focal edema
• Stage 2 – A wound progressing toward the dermis. An abrasion, blister and partial skin loss involving epidermis and/or dermis.
• Stage 3 – A wound involving the subcutaneous tissue. Full skin loss involving damage or necrosis of subcutaneous tissue
• Stage 4 – A wound that goes down into the deeper tissue. Necrosis of soft tissue through to underlying muscle, tendon, or bone.

Coding Guidelines for healed or healing Pressure Ulcer

• Section I.C.12.a.4 – Pressure Ulcer documented as healed – no code would be assigned.
• Section I.C.12.a.5 – Pressure Ulcer documented as healing – assign appropriate Pressure Ulcer Stage code based on the documentation in the medical record. If the documentation does not provide information about the stage of the healing Ulcer, assign the appropriate code for Unspecified Stage.Codes for Non-pressure Ulcers of the lower extremity also include site, laterality and severity (depth of the Ulcer). Examples of depth description for Chronic Ulcer of Right Ankle:
• Limited to breakdown of skin – L97.311
• With fat layer exposed – L97.312
• With necrosis of muscle – L97.313
• With necrosis of bone – L97.314
With unspecified severity – L97.319

Code first any associated underlying condition:

• Atherosclerosis
• Gangrene
• Diabetic Ulcers
• Varicose Ulcer
• Chronic Venous Hypertension
• Post-phlebitic Syndrome
• Post-thrombotic Syndrome

CODING GUIDELINE

I.B.14

Documentation for BMI and Pressure Ulcer Stages: For the body mass index (BMI) and Pressure Ulcer Stage codes, code assignment may be based on medical record documentation from clinicians who are not the patient’s provider (i.e. physician or other qualified practitioner legally accountable for establishing the patient’s diagnosis), since this information is typically documented by other clinicians involved in the care of the patient (e.g., a dietician often documents the BMI and nurses often document the Pressure Ulcer Stages). However, the associated diagnosis (such as overweight, obesity, or pressure ulcer) must be documented by the patient’s provider. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient’s attending provider should be queried for clarification.

In ICD-10-CM, terms “Dermatitis” and “Eczema” are used synonymously and interchangeably.

CODING NOTE

An instructional note appears in the Tabular, under codes L27.0 and L27.1, stating to use an additional code for Adverse Effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5).

 

CODING GUIDELINE

I.C.19.e

Adverse Effects, Poisoning, Under-dosing and Toxic Effects: Codes in categories T36-T65 are combination codes that include the substance that was taken as well as the intent.

No additional external cause code is required for poisonings, toxic effects, adverse effects and under-dosing codes.

 

CODING GUIDELINE

I.C.19.e.5.a

Adverse Effect: When coding an Adverse Effect of a drug that has been correctly prescribed and properly administered, assign the appropriate code for the nature of the adverse effect followed by the appropriate code for the Adverse Effect of the drug (T36-T50). The code for the drug should have a fifth or sixth character of 5.

Radiation-related disorders of the skin and subcutaneous tissue now have their own subchapter. Previously in ICD-9-CM, Sunburns were listed in the Injury and Poisoning Chapter.

DEBRIDEMENT

Anyone that has coded for any length of time knows the difference between Excisional and Non-excisional Debridement. This procedure has been under scrutiny by Medicare’s Recovery Auditors (RA previously known as RAC) due to the vast difference in DRG payment.   One of the biggest problems is getting required documentation necessary to code Excisional Debridement. I hate to say, but ICD-10-PCS is not going to make it any easier.

Unlike ICD-9-CM, ICD-10-PCS codes according to root operations. Depending on the method used, a Debridement procedure could actually fit into two different root operations.

• Excision – Cutting out or off, without replacement, a portion of a body part.
• Excisional Debridement would fit this category
• Extraction – Pulling or stripping out or off all or a portion of a body part by the use of force.
• Non-excisional Debridement would fit this category

It is not enough for a physician to state they did an Excisional or Non-excisional Debridement. In order to code this procedure correctly there are documentation requirements that must be met.

• Condition requiring Debridement
• Location of wound
• Depth of Debridement – code to the deepest layer
• Method of Debridement (sloughing off tissue, cutting away etc.)
• Specific tissue removed (skin, bone, muscle etc.) – cutting back to pink tissue or removal of necrotic tissue does not help with coding the procedure. It does not describe the type of tissue removed.
• Instruments used (scissors, scalpel etc.)

Sometimes coders tend to think that the type of instrument alone is indicative as to the type of Debridement that was performed. This is not always true. A scalpel and/or scissors can be used to cut or scrap the wound. The physician should accurately describe in detail each bullet listed above in his/her procedure note.

Please note, there is no default code for Debridement.   There must be precise documentation within the record and/or procedure note.   Physicians should always be queried anytime documentation provided is not clear.  

On April 1st, President Obama signed into law the Protecting Access to Medicare Act of 2014. Per a White House Press Secretary release this new law “averts cuts to Medicare physician payments that will go into effect on April 1, 2014, under the current-law “sustainable growth rate” system, to extend other health-related provisions set to expire, and to make other changes to current-law health provisions.” In addition to averting cuts to physician payments, this law includes additional “Medicare Extenders” and “Other Health Provisions.” But before looking at some of the more significant topics within the law, it is interesting to note how quickly this bill was presented, voted on and became law.

• March 26, 2014: Representative Joe Pitts (R-PA), Chairman, Energy and Commerce Subcommittee on Health introduced H.R. 4302 the Protecting Access to Medicare Act of 2014.
• March 27, 2014: The House voted by a voice vote and approved the bill. This vote was under special rules that provided for no amendments, limited debate and only needed a two-thirds majority votes.
• March 31, 2014: The United States Senate passed the bill with a vote of 64 YEAs, 35 NAYs and 1 Not Voting.

April 1, 2014: The Act was signed into law by President Obama signed the Protecting Access to Medicare Act of 2014 into Law.

Spotlight on Extensions and Health Provisions in the Law:

Section 101: Physician Payment Update: This section provides for a 0.5 percent update for claims with dates of service on or after January 1, 2014, through December 31, 2013. Further, it provides a zero percent update to the 2015 Medicare Physician Fee Schedule (MPFS) through March 31, 2015.

Section 103: Extension of Therapy Cap Exception Process: This section extends the exceptions process for outpatient therapy caps through March 31, 2015. When a provider requests an exception to the cap for medically necessary services they must submit the KX modifier on their claim. This law extends the application of the caps, exceptions process, and threshold for therapy services provided in a hospital outpatient department (ODP).

Therapy caps for 2014:

 

• Occupational Therapy (OT) cap is $1,920
• Physical Therapy (PT) and Speech-Language Pathology Services (SLP) combined is $1,920

 

Additional information regarding therapy caps can be found on the CMS Therapy Cap webpage as well as Chapter 5, Section 10.3 in the Medicare Claims Processing Manual.

Section 106: Extension of the Medicare-Dependent Hospital (MDH) Program: This program provides enhanced payment to small rural hospitals where Medicare beneficiaries makes up a significant percentage of inpatient days or discharges. This provision extends the program through March 31, 2015.

More information about MDH Hospitals can be found in the Acute Care Hospital Inpatient Prospective Payment System Fact Sheet. Specific criteria to be designated a MDH Hospital includes:

 

• It is rural (located in a rural area);
• It has 100 or fewer beds during the cost reporting period;
• It is not also classified as a Sole Community Hospital (SCH); and
• At least 60 percent of its inpatient days or discharges were attributable to Medicare Beneficiaries entitled to Part A during the hospital’s cost reporting period.

 

Section 111: Extension of Two-Midnight Rule:

For hospital staff closely involved in trying to implement the Two-Midnight Rule, I felt it was important to provide you with the exact language in the bill.

“(a) CONTINUATION OF CERTAIN MEDICAL REVIEW ACTIVITIES.— The Secretary of Health and Human Services may continue medical review activities described in the notice entitled ‘‘Selecting Hospital

Claims for Patient Status Reviews: Admissions On or After October 1, 2013’’, posted on the Internet website of the Centers for Medicare & Medicaid Services, through the first 6 months of fiscal year

2015 for such additional hospital claims as the Secretary determines appropriate. (b) LIMITATION.—The Secretary of Health and Human Services shall not conduct patient status reviews (as described in such notice) on a post-payment review basis through recovery audit contractors under section 1893(h) of the Social Security Act (42 U.S.C. 1395ddd(h)) for inpatient claims with dates of admission October 1, 2013, through March 31, 2015, unless there is evidence of systematic gaming, fraud, abuse, or delays in the provision of care by a provider of services (as defined in section 1861(u) of such Act (42 U.S.C. 1395x(u))).”

What does this mean for hospitals?

 

• The Medicare Administrative Contractor (MAC) Probe and Educate program has now been extended for a fourth time through March 31, 2015.
• Recovery Audit Contractors “shall not conduct patient status reviews on a post-payment review basis” for inpatient claims with dates of service October 1, 2013 through March 31, 2015. It is important to remember that on February 18th CMS announced that current RAC activity is winding down during the new contract procurement round.
• Hospitals should take advantage of this additional time to continue to educate staff and fine tune your processes.

Section 212: Delay in Transition for ICD-9 to ICD-10 Code Sets

“The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD–10 code sets as the standard for code sets under section 1173(c) of the Social Security Act (42 U.S.C. 1320d–2(c)) and section 162.1002 of title 45, Code of Federal Regulations.”

This is a significant delay for everyone that has been proactively planning and providing education for an October 1, 2014 transition to the ICD-10 Code Sets. MMP plans to continue to provide I-10 Corner articles and encourages all to not look at this as a setback but as an opportunity to provide more training to your staff and test the readiness of your computer systems.

Section 221: Medicaid DSH

This law delays reductions in payments to Disproportionate Share Hospitals (DSH) by a year and then makes additional reductions through 2024.

There are still quite a few extensions and provisions not discussed in this article. MMP encourages those interested to review the Protecting Access to Medicare Act of 2014 in its entirety.

For this edition of the I-10 Corner, we have included some helpful hints that will make coding procedures in the Endocrine System a little easier.   To gain familiarity, practice looking up procedures in the ICD-10-PCS coding book that are performed at your facility on a routine basis.

Knowing the Root Operations is the key to making all of this work!                                              

FROM THE ICD-10-PCS REFERENCE MANUAL

Examples of Root Operations

Excision—Root operation B

Definition: Cutting out or off, without replacement, a portion of a body part

Explanation: The qualifier Diagnostic is used to identify excision procedures that are biopsies

Examples: Partial thyroidectomy, ovarian biopsy

Excision is coded when a portion of a body part is cut out or off using a sharp instrument. All root operations that employ cutting to accomplish the objective allow the use of any sharp instrument, including but not limited to

• Scalpel
• Wire
• Scissors
• Bone saw
• Electrocautery tip

Resection—Root operation T

Definition: Cutting out or off, without replacement, all of a body part

Explanation: N/A

Examples: Total nephrectomy, total lobectomy of lung

Resection is similar to Excision, except Resection includes all of a body part, or any subdivision of a body part that has its own body part value in ICD-10-PCS, while Excision includes only a portion of a body part.

Release—Root operation N

Definition: Freeing a body part from an abnormal physical constraint by cutting or by use of force

Explanation: Some of the restraining tissue may be taken out but none of the body part is taken out

Examples: Adhesiolysis of right ovary

The objective of procedures represented in the root operation Release is to free a body part from abnormal constraint. Release procedures are coded to the body part being freed. The procedure can be performed on the area around a body part, on the attachments to a body part, or between subdivisions of a body part that are causing the abnormal constraint.

Reposition—Root operation S

Definition: Moving to its normal location or other suitable location all or a portion of a body part

Explanation: The body part is moved to a new location from an abnormal location, or from a normal location where it is not functioning correctly. The body part may or may not be cut out or off to be moved to the new location

Examples: Reposition of undescended testicle

Reposition represents procedures for moving a body part to a new location. The range of Reposition procedures includes moving a body part to its normal location, or moving a body part to a new location to enhance its ability to function.

Laterality is necessary in code assignment for the following organs:

• Thyroid
• Ovaries
• Testicles
• Adrenals

EXAMPLE

‍

Don’t Forget: 0 vs O:

FROM THE ICD-10-PCS REFERENCE MANUAL

Values

One of 34 possible values can be assigned to each character in a code: the numbers 0 through 9 and the [whole] alphabet (except I and O, because they are easily confused with the numbers 1 and 0).

 

FROM THE ICD-10-CM OFFICIAL GUIDELINES FOR CODING AND REPORTING 2014
B4. Body Part

B4.3 Bilateral body part values are available for a limited number of body parts. If the identical procedure is performed on contralateral body parts, and a bilateral body part value exists for that body part, a single procedure is coded using the bilateral body part value. If no bilateral body part value exists, each procedure is coded separately using the appropriate body part value.

 

This edition addresses some of the changes found in the Endocrine System. Please refer to your ICD-10-CM code book to gain familiarity with the codes as this chapter has significantly expanded. Then try to notice what documentation is missing from the records you are reviewing so that you can advise your physicians on what is needed for I-10. Once again, brushing up on your Anatomy and Physiology will also be crucial for this chapter.

The Endocrine System consists of glands of the body that secrete hormones into the blood stream. The word Hormone means to set in motion. Hormones start the process of change in:

• Cells of specific body tissues
• A single organ
• A group of organs
• All cells of the body

Did you know? There are other organs in the body that produce hormones but, that is not their main function, such as the heart and stomach.

What Changed in the Endocrine Chapter?

• The diseases of the endocrine, nutritional, and metabolic diseases moved from Chapter 3 in I-9 to Chapter 4 in I-10
• Certain disorders of the immune system have been moved out of the endocrine chapter and into Chapter 3 in I-10, "Diseases of the Blood, Blood Forming Organs, and Certain Disorders".
• Gout was moved out of the Endocrine chapter and placed in Chapter 13, "Diseases of the Musculoskeletal System and Connective Tissue".
• The type and cause of Cushing's Syndrome is now needed to assign the correct code.
• More information is required to assign the correct code.
• For example: Congenital Hypothyroidism- The code has been expanded and we now must know if there is documentation of a goiter in order to assign the appropriate code.
• Diabetes Mellitus
• Many code titles were revised

Notice below how the two code sets differ. Chapter 4 has more than doubled in size!

DEFINITON

It will be Easy to remember that the Endocrine chapter codes begin with the letter E!

Diabetes Mellitus
One of the major changes we see in I-10 is in the Endocrine System for Diabetes Mellitus. First of all, Diabetes has its own subchapter heading. And, in I-9, Diabetes was classified to one category, 250. Now there are 5 categories for Diabetes in I-10 and they are listed below:

• E08, Diabetes Mellitus due to underlying condition
• E09, Drug or chemical induces Diabetes Mellitus
• E10, Type 1 Diabetes Mellitus
• E11, Type 2 Diabetes Mellitus
• E13, Other specified Diabetes Mellitus

Please note: "Use additional code to identify any insulin use (Z79.4)" is to be used with all diabetic cases except for Type 1. This additional insulin code is not assigned for Type 1 diabetic cases because insulin is required to maintain life.

The diabetic codes were expanded to reveal manifestations and complications of the disease via 4th or 5th characters instead of using an additional code to identify the manifestation.

FROM THE MANUAL

Here is an example of how the diabetic codes have been expanded to include more information as compared to I-10:

‍NOTE FROM AUTHOR
Trying to code controlled and uncontrolled diabetes is no longer a coding issue! Even better, we can capture inadequately controlled, out of control, and poorly controlled diabetes and code it to Diabetes Mellitus, by type with hyperglycemia.

 

DEFINITON

‍Hemoglobin A1c: 7 is not a lucky number when it comes to Diabetes!

A1C is a blood test that will determine an average blood sugar reading over a period of 3 months and will reveal how well diabetes is being controlled. An A1c level of <7% is the goal for all diabetics. The higher the A1c level, the higher the risk of developing diabetic complications. The table shows an A1c with the corresponding estimated average glucose reading (eAG).

FYI - Secondary Diabetes Mellitus
This type of diabetes is caused by another disease or condition. The code title has changed in I-10 for Secondary Diabetes:

I-9 Secondary diabetes mellitus, 249.0
vs.
I-10 Diabetes due to underlying condition, E08

NOTE FROM AUTHOR
Pay attention to the code instructions under E08 when coding Secondary Diabetes:
Code first the underlying condition, such as:

• Congenital Rubella (P35.0)
• Cushing's Syndrome (E24.-)
• Cystic Fibrosis (E84.-)
• Malignant Neoplasm (C00-C96)
• Malnutrition (E40-E46)
• Pancreatitis and other diseases of the pancreas (K85.-, K86.-)

Use additional code to identify any insulin use (Z79.4)

 

Coding Guidelines for Diabetes Mellitus

FROM THE ICD-10-CM OFFICIAL GUIDELINES FOR CODING AND REPORTING 2014

Coding Guideline I.C.4.a., Diabetes Mellitus
The diabetes mellitus codes are combination codes that include the type of diabetes mellitus, the body system affected, and the complications affecting the body system. As many codes within a particular category as are necessary to describe all of the complications of the disease may be used. They should be sequenced based on the reason for a particular encounter. Assign as many codes from categories E08-E13 as needed to identify all of the associated conditions that the patient has.

Coding Guideline I.C.4.a.5 (a), Underdose of insulin due to insulin pump failure
An underdose of insulin due to an insulin pump failure should be assigned to a code from subcategory T85.6, Mechanical complication of other specified internal and external prosthetic devices, implants and grafts, that specifies the type of pump malfunction, as the principal or first-listed code, followed by code T38.3x6-, Underdosing of insulin and oral hypoglycemic [antidiabetic] drugs. Additional codes for the type of diabetes mellitus and any associated complications due to the underdosing should also be assigned.

Coding Guideline I.C.4.a.6., Secondary Diabetes Mellitus
Codes under categories E08, Diabetes mellitus due to underlying condition, and E09, Drug or chemical induced diabetes mellitus, identify complications/manifestations associated with secondary diabetes mellitus. Secondary diabetes is always caused by another condition or event (e.g., cystic fibrosis, malignant neoplasm of pancreas, pancreatectomy, adverse effect of drug, poisoning).

Coding Guideline I.C.4.a.6.b., Assigning and Sequencing Secondary Diabetes Codes and Its Causes
The sequencing of the secondary diabetes codes in relationship to codes for the cause of the diabetes is based on the Tabular List instructions for categories E08 and E09.

There are expanded instructions in Chapter 4 for coding late effects now called "Sequelae" in I-10.

EXAMPLE FROM ICD-10-CM CODER TRAINING MANUAL
Excludes 1 notes have been added to some categories between E50-E63 to indicate that the sequelae of the nutritional deficiency are assigned a code from category E64.

 

This material was compiled to share information. MMP is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

 

PNEUMONIA

Pneumonia is a common illness seen in the healthcare industry that affects millions of people each year in the United States. Bacteria are the most common cause of pneumonia in adults.

• Community Acquired Pneumonia (CAP) is acquired by people that have not recently been hospitalized or live in some type of healthcare facility such as a nursing home.
• Healthcare Associated Pneumonia (HCAP) is acquired by people while they’ve been in a healthcare facility such as a nursing home.
• Hospital Acquired Pneumonia (HAC) is acquired while a patient is hospitalized.

NOTE FROM AUTHOR
When a patient is admitted to the hospital with either HCAP or HAC, code Y95 for Nosocomial Condition should also be added – Refer to Coding Clinic 4th Qtr. 2013 page 118.

External sources may also be the source of Pneumonia.

• Aspiration Pneumonia – Caused by the inhalation of foreign material such as food, liquids, vomit or gastric secretions.
• Pneumonitis due to Inhalation of Food and Vomit – J69.0
• Code also any associated foreign body in the respiratory tract from category T17
• Pneumonitis due to Inhalation of Oil and Essences – J69.1
• Code first (T51-T65) to identify substance
• Pneumonitis due to Inhalation of Other Solids and Liquids – J69.8
• Code first (T51-T65) to identify substance
• Radiation Pneumonitis (J70.0) – Due to exposure of therapeutic doses of radiation.
• Use additional code (W88-W90, X39.0) to identify the external cause
• Ventilator Assisted Pneumonitis – J95.851

NOTE FROM MANUAL

Official ICD-10-CM Guidelines for Coding and Reporting – Section I.C.10.d.1

As with all procedural or post-procedural complications, code assignment is based on the provider’s documentation of the relationship between the condition and the procedure. Code J95.851, should be assigned only when the provider has documented Ventilator Associated Pneumonia (VAP). An additional code to identify the organism (e.g., Pseudomonas aeruginosa, code B96.5) should also be assigned. Do not assign an additional code from categories J12.0-J18.9 to identify the type of pneumonia.

Code J95.851 should not be assigned for cases where the patient has pneumonia and is on a mechanical ventilator and the provider has not specifically stated that the pneumonia is ventilator-associated pneumonia. If the documentation is unclear as to whether the patient has a pneumonia that is a complication attributable to the mechanical ventilator, query the provider.

 

NOTE FROM MANUAL

Official ICD-10-CM Guidelines for Coding and Reporting – Section I.C.10.d.2

A patient may be admitted with one type of pneumonia (e.g., code J13, Pneumonia due to Streptococcus pneumonia) and subsequently develop ventilator associated pneumonia (VAP) J95.851. In this instance, the principal diagnosis would be the appropriate code from categories J12.0-J18.9 for the pneumonia diagnosed at the time of admission. Code J95.851, Ventilator associated pneumonia, would be assigned as an additional diagnosis when the provider has also documented the presence of ventilator associated pneumonia.

RESPIRATORY FAILURE

In ICD-10-CM there will be combination codes to include Hypoxia and Hypercapnia

Acute Respiratory Failure

• Unspecified Whether with Hypoxia or Hypercapnia – J96.00
• With Hypoxia – J96.01
• With Hypercapnia – J96.02

Chronic Respiratory Failure

• Unspecified Whether with Hypoxia or Hypercapnia – J96.10
• With Hypoxia – J96.11
• With Hypercapnia – J96.12

Acute on Chronic Respiratory Failure

• Unspecified Whether with Hypoxia or Hypercapnia – J96.20
• With Hypoxia – J96.21
• With Hypercapnia – J96.22

Respiratory Failure, Unspecified

• Unspecified Whether with Hypoxia or Hypercapnia – J96.90
• With Hypoxia – J96.91
• With Hypercapnia – J96.92

Post-procedure Respiratory Failure

            Excludes 1 – Respiratory Failure in other conditions (J96)

• Acute Post-procedure Respiratory Failure – J95.821
• Acute and Chronic Post-procedure Respiratory Failure – J95.822

Respiratory Failure is always due to an underlying condition. Sequencing will be dependent on the circumstances of the admission. If two conditions are equally responsible and there are no chapter specific guidelines, the guideline for two or more diagnosis that equally meets the definition of principal diagnosis may be applied.

If the documentation is not clear as to whether Acute Respiratory Failure and another condition are equally responsible for occasioning the admission, query the provider for clarification.

Official Guidelines for Coding and Reporting – Section I.C.10.b.3

BRONCHITIS

Manifestations of Acute Bronchitis can now be reflected in ICD-10-CM under category J20.

Acute Bronchitis due to:

• Mycoplasma Pneumoniae – J20.0
• Hemophilus Influenza – J20.1
• Streptococcus – J20.2
• Coxsackievirus – J20.3
• Parainfluenza Virus – J20.4
• Respiratory Syncytial Virus – J20.5
• Rhinovirus – J20.6
• Echovirus – J20.7
• Other Specified Organism – J20.8
• Unspecified – J20.9

EMPHYSEMA

Emphysema is a type of Chronic Obstructive Pulmonary Disease (COPD) involving damage to the air sacs (alveoli) in the lungs.

ICD-10 will now have codes to cover two different forms of Emphysema.

• Panlobular Emphysema (J43.1) - alveolar destruction occurs in all alveoli within the lobule simultaneously.
• Centrilobular Emphysema (J43.2) - destruction that begins at the center of the lobule.

When reporting categories for COPD (J44), Asthma (J45), Chronic Bronchitis (J42) and Emphysema (J43), an additional code should be assigned to show any specific external factors such as:

• Exposure to environmental tobacco smoke (Z77.22)
• Exposure to tobacco smoke in the perinatal period (P96.81)
• History of tobacco use (Z87.891)
• Occupational exposure to environmental tobacco smoke (Z57.31)
• Tobacco dependence (F17-)
• Tobacco use (Z72.0)

SINUSITIS

In ICD-10, there will also be individual codes for Acute Sinusitis, Acute Recurrent Sinusitis and Chronic Sinusitis for each individual sinus cavity.

• Acute Sinusitis – defined as symptoms of less than 4 weeks’ duration.
• Maxillary – J01.00
• Frontal – J01.10
• Ethmoidal – J01.20
• Sphenoidal – J01.30
• Pansinusitis – J01.40
• Other Acute Sinusitis – J01.80
• Acute Sinusitis, Unspecified – J01.90
• Acute Recurrent Sinusitis – defined as three or more episodes per year, with each episode lasting less than 2 weeks.
• Maxillary – J01.01
• Frontal – J01.11
• Ethmoidal – J01.21
• Sphenoidal – J01.31
• Pansinusitis – J01.41
• Other Acute Recurrent Sinusitis – J01.81
• Acute Recurrent Sinusitis, Unspecified – J01.91
• Chronic Sinusitis – defined as symptoms lasting longer than 8 weeks.
• Maxillary – J32.0
• Frontal – J32.1
• Ethmoidal – J32.2
• Sphenoidal – J32.3
• Pansinusitis – J32.4
• Other Chronic Sinusitis – J32.8
• Other Chronic Sinusitis, Unspecified – J32.9

Pansinusitis is when each sinus cavity on one or both sides of the face is affected. When multiple sinus cavities are affected but not Pansinusitis, a code from Other Acute, Acute Recurrent or Chronic (J01.80, J01.81 or J32.8) should be assigned.

Note:   When a respiratory condition is described as occurring in more than one site and is not specifically indexed, it should then be classified to the lower anatomic site. One example would be Tracheobronchitis to Bronchitis – J40.

INFLUENZA

NOTE FROM MANUAL

Official ICD-10-CM Guidelines for Coding and Reporting – Section I.C.10.C

Code only confirmed cases of influenza due to certain identified influenza viruses (category J09), and due to other identified influenza virus (category J10). This is an exception to the hospital inpatient guideline Section II, H. (Uncertain Diagnosis).

In this context, “confirmation” does not require documentation of positive laboratory testing specific for avian or other novel influenza A or other identified influenza virus. However, coding should be based on the provider’s diagnostic statement that the patient has avian influenza, or other novel influenza A, for category J09, or has another particular identified strain of influenza, such as H1N1 or H3N2, but not identified as novel or variant, for category J10.

If the provider records “suspected” or “possible” or “probable” avian influenza, or novel influenza, or other identified influenza, then the appropriate influenza code from category

J11, Influenza due to unidentified influenza virus, should be assigned. A code from category J09, Influenza due to certain identified influenza viruses, should not be assigned nor should a code from category J10, Influenza due to other identified influenza virus.

Subcategory J10.8 - Influenza due to Other Identified Influenza Virus with Other Manifestation has been expanded to reflect the manifestations of the Influenza.

Influenza Due to Other Identified Influenza Virus with -

• Encephalopathy – J10.81
• Myocarditis – J10.82
• Otitis Media – J10.83
• Other Manifestation – J10.89

To derive at the most appropriate code for any condition, be sure to always read the additional instructions and Excludes Notes in your coding book and/or encoder.

Over the next several months a lot of information will be posted concerning the do’s and don’ts of ICD-10-CM. At times it may be overwhelming. You will find the transition to be easier and less stressful the earlier you start training.

This week the focus will be on the Respiratory System. Many familiar conditions are identified in this chapter such as Asthma, COPD and Pneumonia.

The Respiratory System is made up of organs and tissues that enable us to breathe.

Airways

• Mouth
• Nose and Nasal Cavities
• Pharynx
• Larynx
• Trachea
• Bronchial Tubes or Bronchi, and their tubes

Lungs

• Right Lung – 3 lobes
• Upper
• Middle
• Lower
• Left Lung – 2 lobes
• Upper
• Lower

Lower Linked Vessels – Provide pulmonary circulation

Muscles

• Diaphragm
• Intercostal
• Abdominal
• Muscles in the Neck and Collarbone area – (accessory muscles)

Here is a list of common signs and symptoms seen in the Respiratory System that may be indicative of a more severe condition. Keep in mind, you always want to be as specific as possible when coding for appropriate reimbursement and data quality.

• Cough
• Dyspnea
• Asphyxia
• Shortness of breath
• Epistaxis
• Hemoptysis
• Rales
• Hypoxemia
• Intercostal pain
• Tachypnea
• Hyperventilation
• Respiratory arrest

Categories J00 – J99

• J00 – J06 Acute Upper Respiratory Infections
• J09 – J18 Influenza and Pneumonia
• J20 – J22 Other Acute Lower Respiratory Infections
• J30 – J39 Other Diseases of Upper Respiratory Tract
• J40 – J47 Chronic Lower Respiratory Diseases
• J60 – J70 Lung Diseases due to External Agents
• J80 – J84 Other Respiratory Diseases Principally Affecting the Interstitium
• J85 – J86 Supportive and Necrotic Conditions of the Lower Respiratory Tract
• J90 – J94 Other Diseases of the Pleura
• J95 Intraoperative and Postprocedural Complications and Disorders of Respiratory System, Not Elsewhere Classified
• J96 – J99 Other Diseases of the Respiratory System

Classification changes in ICD-10 will provide greater specificity.

While the overall organization of ICD-10 is similar to ICD-9, diseases have been rearranged. Certain diseases/disorders have been removed from other chapters and placed in Chapter 10.

• Streptococcal Pharyngitis (J02.0) now classified in Chapter 10, no longer will be classified with the Infectious and Parasitic Disease Chapter.
• Ventilator Associated Pneumonia (J95.851) was previously found in the “Injury and Poisoning” Chapter in ICD-9-CM.
• Intraoperative and post-procedure complications pertaining to the Respiratory System have been grouped together in Chapter 10 – J95.

Some codes in Chapter 10 have been expanded to include notes indicating that an additional code should be assigned or an associated condition should be sequenced first. Example:

• Use additional code to identify the infectious agent
• Use additional code to identify the virus
• Code first any associated lung abscess
• Code first the underlying disease
• Use additional code to identify other conditions such as tobacco use or exposure

As with any chapter in ICD-10, coders must be familiar with the Official Coding Rules and Guidelines. Refer to http://www.cdc.gov/nchs/data/icd/icd10cm_guidelines_2014.pdf.

COPD and ASTHMA

Many of the instructions in ICD-9-CM pertaining to COPD have been eliminated in ICD-10-CM. Here are the two hair splitting requirements in ICD-9 that have been eliminated in ICD-10:

• Physicians will no longer have to distinguish Asthma as Intrinsic or Extrinsic.
• Will no longer need separate codes for “Chronic Obstructive Asthma”, as opposed to “Chronic Obstructive Bronchitis” or plain ole “COPD”.
• In ICD-10-CM, Asthma is just Asthma and COPD is just COPD.

If a patient is documented with both COPD and Asthma, two codes will be required to show each condition.

EXAMPLE
Patient presented to ER with gradual increase in shortness of breath which was unresponsive to home nebulizer treatments. In the ER, patient received more respiratory treatments; however, the patient was admitted after he failed to improve. Theophylline level was 5.9 upon admission. Chest x-ray showed no evidence of active infiltrates. The patient was bolused with IV Steroids and started on frequent respiratory therapy treatments. IV Aminophylline boluses and drip were used to increase his theophylline level to therapeutic range. The patient gradually cleared and by the next day was much better. IV Aminophylline was changed to PO. The Ventolin treatments were decreased to q 4 hr. and his Steroids were rapidly tapered back to 10 mg of Prednisone.

Discharge Diagnosis: Moderate persistent Asthma with Status Asthmaticus – J45.42
Acute Exacerbation of COPD – J44.1

NOTE FROM MANUAL

Official ICD-10-CM Guidelines for Coding and Reporting – Section I.C.10.a

The Codes in categories J44 and J45 distinguish between uncomplicated cases and those in acute exacerbation.

An acute exacerbation is a worsening or a decompensation of a chronic condition. An acute exacerbation is not equivalent to an infection superimposed on a chronic condition, though an exacerbation may be triggered by an infection.

Terminology terms have been updated and added to reflect current the clinical classification of Asthma – J45. Asthma must be documented as mild, moderate or severe. Mild Asthma must be documented as intermittent or persistent.

DEFINITON

‍

• Mild intermittent Asthma
• Uncomplicated – J45.20
• With (Acute) Exacerbation – J45.21
• With Status Asthmaticus – J45.22
• Mild persistent Asthma
• Uncomplicated – J45.30
• With (Acute) Exacerbation – J45.31
• With Status Asthmaticus – J45.32
• Moderate persistent Asthma
• Uncomplicated – J45.40
• With (Acute) Exacerbation – J45.41
• With Status Asthmaticus – J45.42
• Severe persistent Asthma
• Uncomplicated – J45.50
• With (Acute) Exacerbation – J45.51
• With Status Asthmaticus – J45.52

Intrinsic (non-allergic) and Extrinsic (allergic) Asthma will both be classified to J45.909 – Unspecified Asthma, Uncomplicated.

MMP highly recommends an early start with ICD-10-CM/PCS training. There is no doubt the transition will be challenging. Any type of procrastination is sure to bring on stress with increased complexity and costs. Early planning and preparation will be the key to a smooth and successful transition. For timely updates and informative articles, Continue to follow MMP through their weekly newsletter Wednesday@One Part 2 of Chapter 10 – Diseases of the Respiratory System will post March 12, 2014.

Illustration: Gray, Henry. Anatomy of the Human Body. Philadelphia: Lea & Febiger, 1918; Bartleby.com, 2000. www.bartleby.com/107/. [Date of Printout].

 

For the I-10 Corner this week, we are discussing a few of the specific coding differences for cardiac diagnoses and conditions in ICD-9-CM and ICD-10-CM.

Angina Pectoris with Atherosclerotic Heart Disease (ASHD):

I-9

Angina, Unspecified (413.9)

ASHD, Unspecified (414.00)

I-10

Angina with ASHD, Unspecified—see Arteriosclerosis, Coronary (artery), Unspecified (I20.9)

NOTE FROM AUTHOR
Attention: Two codes in I-9 vs. one code in I-10

Atrial Fibrillation:

I-9

Atrial Fibrillation (established) (paroxysmal) (427.31)

I-10

Atrial Fibrillation or Auricular (established) (I48.91)

Chronic (I48.2)

Paroxysmal (I48.0)

Permanent (I48.2)

Persistent (I48.1)

Atrial Flutter:

I-9

Atrial Flutter or Auricular (427.32)

I-10

Atrial Flutter or Auricular (I48.92)

Atypical (I48.4)

Type I (I48.3)

Type II(48.4)

Typical (I48.3)

 

NOTE FROM AUTHOR
Attention: There are specific descriptions for Atrial Fibrillation and Atrial Flutter in I-10. In addition, there are no specific codes for Postoperative Fibrillation or Postoperative Flutter in the alpha index.

Heart Failure:

I-9

Congestive Heart Failure (compensated) (decompensated) (428.0)

Diastolic (428.30)

Acute (428.31)

Acute on Chronic (428.33)

Chronic (428.32)

Systolic (428.20)

Acute (428.21)

Acute on Chronic (428.23)

Chronic (428.22)

I-10

Congestive Heart Failure (compensated) (decompensated) (I50.9)

Diastolic (congestive) (I50.30)

Acute (congestive) (I50.31)

            and (on) chronic (congestive) (I50.33)

Chronic (congestive) (I50.32)

            and (on) acute (congestive) (I50.33)

Combined with Systolic (congestive) (I50.40)

            Acute (congestive) (I50.41)

                        And (on) chronic (congestive) (I50.43)

            Chronic (congestive) (I50.42)

                        And (on) acute (congestive) (I50.43)

Systolic (congestive) (I50.20)

Acute (congestive) (I50.21)

            and (on) chronic (congestive) (I50.23)

Chronic (congestive) (I50.22)

            and (on) acute (congestive) (I50.23)

Combined with Diastolic (congestive) (I50.40)

            Acute (congestive) (I50.41)

                        And (on) chronic (congestive) (I50.43)

            Chronic (congestive) (I50.42)

                        And (on) acute (congestive) (I50.43)

Myocardial Infarction (MI):

I-9

Infarct, Myocardial (acute or with a stated duration of 8 weeks or less) (with Hypertension) (410.9x)

NOTE FROM MANUAL
Note—Use the following fifth-digit subclassification with category 410:

0 - episode unspecified

1 - initial episode

2 - subsequent episode without recurrence

 

I-10

Infarct, Myocardial (acute) (with stated duration of 4 weeks or less) (I21.3)

NOTE FROM AUTHOR
Attention:

• For the episode of care in I-10, MIs are identified as either Acute (I21.xx) or Subsequent (I22.xx).
• The timeframe (stated duration of the MI) has decreased in I-10 to 4 weeks from 8 weeks in I-9.

           

Most MIs are considered to be ST-Elevation (STEMI) unless stated as Non-ST Elevation (NSTEMI) or Subendocardial.

STEMI

Anterior (anteroapical) (anterolateral) (anteroseptal) (Q wave) (wall) (I21.09)

Inferior (I21.09) (diaphragmatic) (inferolateral) (inferoposterior) (wall) NEC (I21.19)

Inferoposterior Transmural (Q wave) (I21.11)

Lateral (I21.29) (apical-lateral) (basal-lateral) (high) (I21.29)

Posterior (I21.29) (posterobasal) (posterolateral) (posteroseptal) (true) I21.29)

Septal (I21.29)

Specified NEC (I21.29)

NSTEMI

Subendocardial (I21.4)

Non-Q wave NOS (I21.4)

Nontransmural NOS (I21.4)

If NSTEMI evolves to STEMI, assign the STEMI code. If STEMI converts to NSTEMI due to thrombolytic therapy, it is still coded as STEMI.

NOTE FROM AUTHOR
For Acute MIs, we can now identify the specific coronary artery impacted. For example, per the alpha index:

Infarct, Myocardial, Involving

Coronary artery of anterior wall NEC (I21.09)

Coronary artery of inferior wall NEC (I21.19)

Diagonal coronary artery (I21.02)

Left anterior descending coronary artery (I21.02)

Left circumflex coronary artery (I21.21)

Left main coronary artery (I21.01)

Oblique marginal coronary artery (I21.21)

Right coronary artery (I21.11)

Please refer to the our article, ICD-10-CM Diseases of the Circulatory System, describing specific coding guidelines for cardiac diagnoses and conditions.

I hope this article has been beneficial in helping you become more familiar with cardiac diagnoses and conditions in ICD-10-CM.           

 

For the I-10 Corner this week, we’re discussing a few of the procedural coding guidelines for Cardiac Bypass Procedures, including a few examples.

Remember: The letters I and O and not used in PCS since they are easily confused with numbers one (1) and zero (0).

ICD-10-PCS Coding Guidelines

Coronary Bypass Procedures

B3.6b. Coronary arteries are classified by number of distinct sites treated, rather than number of coronary arteries or anatomic name of a coronary artery (e.g., left anterior descending). Coronary artery bypass procedures are coded differently than other bypass procedures as described in guideline B3.6a. Rather than identifying the body part bypassed from, the body part identifies the number of coronary artery sites bypassed to, and the qualifier specifies the vessel bypassed from.

Example: Aortocoronary artery bypass of one site on the left anterior descending coronary artery and one site on the obtuse marginal coronary artery is classified in the body part axis of classification as two coronary artery sites and the qualifier specifies the ‘aorta’ as the body part bypassed from.

B3.6c. If multiple coronary artery sites are bypassed, a separate procedure is coded for each coronary artery site that uses a different device and/or qualifier.

Example: Aortocoronary artery bypass and internal mammary coronary artery bypass are coded separately.

Coronary Excision for Graft

B3.9. If an autograft is obtained from a different body part in order to complete the objective of the procedure, a separate procedure is coded.

Example: Coronary bypass with excision of saphenous vein graft; excision of saphenous vein is coded separately.

Coding Example: CABG of LAD using left internal mammary artery, open; off pump (02100Z9). Root Operation: Bypass, Coronary Artery, One Site, (0210), Open (0), No Device (z), Internal Mammary, Left (9).

                Note: The Internal Mammary Artery = No Device. It is not considered graft material.

Coding Example: Open coronary artery bypass graft of three coronary arteries using left autologous greater saphenous vein (021209w). Root Operation: Bypass, Coronary Artery, Three Sites (0212), Open, (0), Autologous Venous Tissue (9), Aorta (w).

Note: For Coronary Bypass, the Body Part identifies the number of coronary artery sites bypassed to-- which is the Aorta.

Coronary Body Parts

B4.4 The coronary arteries are classified as a single body part that is further specified by number of sites treated and not by name or number or arteries. Separate body part values are used to specify the number of sites treated when the same procedure is performed on multiple sites in the coronary arteries.

Example: Angioplasty of two distinct sites in the left anterior descending coronary artery with placement of two stents is coded as Dilation of Coronary Arteries, Two Sites, with Intraluminal Device.

Example: Angioplasty of two distinct sites in the left anterior descending coronary artery, one with stent placed and one without, is coded separately as Dilation of Coronary Artery, One Site, with Intraluminal Device, and Dilation of Coronary Artery, One Site, with no device.

Coding Example: PTCA of two coronary arteries: RCA with stent (intraluminal device) (02703DZ) and LAD without stent (02703ZZ). Root Operation: Dilation, Artery, Coronary, One Site (0270)—one with an intraluminal device and one without.

Note: Coronary arteries are counted as single body parts. It doesn’t matter how many arteries were treated. The main distinguishing factor is the number of sites treated.

MMP hopes this article was beneficial in helping you become more familiar with cardiac bypass procedures in ICD-10-PCS.